What? An OIG report without doom and gloom? Fire and brimstone?

• Slides

In February, 2024 the OIG released an audit report of telehealth E/M services performed between March 2020 and November 2020. During this nine-month period practitioners submitted claims for 19 million E/M services. Before I talk about the report though, let me congratulate everyone who was working in healthcare during that time and responded to the multiple changes in rules for telehealth, and kept your practice open and got claims paid. That was no small feat.

Before I get into the details, read this astonishing sentence from the report.

“This report does not have recommendations because providers generally met Medicare requirements when billing for E/M services provided via telehealth and unallowable payments we identified resulted primarily from clerical errors and the inability to access records.”

Perhaps some of you have seen a sentence similar to this in an OIG report before, but this is a first for me. The OIG did identify some issues in a section on “other matters.” I’ll review those at the end.

The OIG selected a random sample of 110 claims that were indicated as telehealth either through the place of service (02) or modifier (95, GT, GQ, G0). Only five of the claims did not meet the criteria. For four out of the five, the OIG did not receive any records. The report reminds us that these services were performed before the 2021 changes for E/M services. The March 2020 interim rule allowed practitioners to use either time or medical decision-making to select the level of service for telehealth visits, dropping the requirement of key components history and exam that were in effect in 2020.

OIG Prior reports on Telehealth

The OIG has issued other reports on telehealth services that were performed during the public health emergency (PHE). In one of them, the OIG identified 1,700 healthcare providers whose billings post a high risk to Medicare. They identified these providers by volume. That is, these clinicians we’re billing more services than were typically feasible in a 24-hour period. The current report pulled a random sample of E/M claims and did not focus on any individual’s coding profile or volume.

General documentation guidelines

This report quotes the general principles of documentation from the 1995/1997 Documentation Guidelines, and says, “E/M documentation should generally conform” to those principles. (These principles are listed at the end of this article, in case you can’t put your hands on the 1995/1997 guidelines at the moment). I would emphasize the second point on the list.

“The documentation of each patient encounter should include: reason for encounter and relevant history, physical examination findings, and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identify of the observer.”

Other matters: potential documentation issues

But, it’s not all peaches and cream in the report. (last mixed metaphor, I promise.) The records the OIG reviewed were from the first nine months of the PHE. I want to emphasize the incredible work of coders, billers, practice managers and practitioners, getting claims with conflicting and ever-changing rules. The grids by payer… Here are issues that the OIG mentioned. The first two don’t seem relevant to me.

• Time wasn’t documented and the note didn’t say if the patient was new or established. Time isn’t required, time or MDM could be used (and can be used) and although some records say if it is a new patient or follow up, that isn’t required either. A payer can check claims history.
• The OIG noted that some providers didn’t sign the medical record. That is a problem. Practitioners must sign and date their encounters.

The issues related to telehealth itself included not indicating if the service was audio/visual or audio only, what technology was used, the location of the provider or enrollee. As I’ve looked at notes, some of these problems have been solved with better templates. While some notes do describe what software was used, it isn’t universal. And unlike in 2020, a HIPAA compliant technology is now required.

Typically, CMS responds to the recommendations in an OIG report, indicating agreement or disagreement and with a plan to address problems. Let’s end this article with one more quote from the report. “CMS elected not to provide comments on our draft.”

The report:

“Medicare generally paid for evaluation and management services provided via telehealth during the first 9 months of the covid-10 public health emergency that met medicare requirements.”  OIG, Feb, 2024. A-01-21-00501.

You can find it here: https://oig.hhs.gov/oas/reports/region1/12100501.asp

See page 17 of the report for a list of other OIG telehealth reports.

General principles of documentation, from the 1995 and 1997 guidelines:

1. The medical record should be complete and legible.
2. The documentation of each patient encounter should include: reason for encounter and relevant history, physical examination findings, and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the observer.
3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
4. Past and present diagnoses should be accessible to the treating or consulting physician.
5. Appropriate health risk factors should be identified.
6. The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.
7. The CPT codes reported on the health insurance claim form should be supported by the documentation in the medical record.